Healthcare Provider Details

I. General information

NPI: 1942388434
Provider Name (Legal Business Name): JOHN ADAM OBUDZINSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. JOHN ADAM OBUDZINSKI

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424-S. 90TH ST. STE 214
WEST ALLIS WI
53227-2455
US

IV. Provider business mailing address

100-15TH AVE. STE 180
SOUTH MILWAUKEE WI
53172-1160
US

V. Phone/Fax

Practice location:
  • Phone: 414-328-8777
  • Fax: 414-328-8777
Mailing address:
  • Phone: 414-768-5430
  • Fax: 414-762-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101006817
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21407-021
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: